Employment and Industrial Relations in the Healthcare Sector

7/27/2019 Employment and Industrial Relations in the Healthcare Sector

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This report is available in electronic format only.

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Employment and industrial relations inthe health care sector

Introduction

Health care sector context

Social partner organisations

Collective bargaining, social dialogue and industrial action in the sectorContribution of collective bargaining and social dialogue to addressing

the challenges facing the sector

Commentary

Bibliography

Annex 1: Country groups and codes
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This report is available in electronic format only.

Wyattville Road, Loughlinstown, Dublin 18, Ireland. - Tel: (+353 1) 204 31 00 - Fax: 282 42 09 / 282 64 56e-mail: [email protected] - website: www.eurofound.europa.eu

This report presents the findings of a study that assessed the contributions of employers, trade

unions and professional organisations in achieving the recruitment and retention of staff (otherthan doctors) in the health care sector as it battles to overcome the challenges of an ageing

population, budgetary constraints and skills shortages. The study covers hospital-based,residential and home care provided in the public and private sectors in the EU27 countries (apart

from Latvia and Finland) plus Norway. The report provides a summary of employment,

expenditure and policy trends in the sector and identifies key social partner organisations. Itexamines collective bargaining and social dialogue and their contribution to addressing the

challenges the sector faces, particularly in increasing its attractiveness as an employer for nursesand care workers by helping to improve their pay, working conditions and terms of employment.

IntroductionThe health care sector is of increasing socio-economic significance in the context of an ageing

population in Europe. By 2030, the population of working age in the EU could be reduced fromthe present 303 million to 280 million. This has implications not only for potential growth and thesustainability of pensions, but also for the funding of the health and social care sector and for the

recruitment of workers to provide these services.The health care sector consumes a high and often increasing share of gross domestic product(GDP) (511% in EU countries). Over 21.5 million people worked in the health and social worksectors in 2009. The workforce in the health care sector is dominated by women, with no lessthan 78% of workers being female.

Although demand for care workers and staff shortages are expected to grow, research shows thatthe sector often offers poorworking conditions and remuneration compared to sectors requiringequivalent levels of skills and training. This has already led to significant mobility of workerswithin and outside the EU, and could serve to exacerbate skills shortages in the future.

Social partner organisations have an important role to play in shaping the attractiveness of thesector as a source of employment, but in many cases, they clearly do so within the constraints of

public (or private) sector budgets, as well as within the framework of existing collectivebargaining and social dialogue arrangements.In order to assess the existing and potential contribution of employers and trade unions inensuring recruitment and retention in this growth sector, this study aims to:

provide a summary of key trends in the sector in relation to employment, health careexpenditure and health care policy trends;

outline the development of the sector and, in particular, the situation of nurses and careworkers with regard to working conditions and terms of employment;

describe industrial relations in the sector with regard to social partner organisations, collectivebargaining and social dialogue both in the private and public sectors;

map and analyse the contribution of social partners to addressing the challenges in the sector

(such as working conditions, supply of qualified staff, ensuring greater gender equality,offering career opportunities, improving quality of care).

The sector covered by this study includes all health care activities including health care inhospitals, residential care and home care (for example, for elderly or disabled individuals),excluding childcare services. In terms of occupational coverage, the study focuses on nurses,midwives, skilled and unskilled care workers. It excludes doctors.


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European Foundation for the Improvement of Living and Working Conditions, 20113

The study covers hospital-based, residential and home care provided in both the public andprivate sectors. The latter includes for profit as well as non-profit organisations such as careservice providers funded by churches and non-governmental organisations (NGOs).

This report is based on contributions provided by the national centres of the EuropeanIndustrial Relations Observatory (EIRO) network. It includes contributions from Austria,Belgium, Bulgaria, Cyprus, the Czech Republic, Denmark, Estonia, Germany, Greece, France,Hungary, Ireland, Italy, Lithuania, Luxembourg, Malta, the Netherlands, Poland, Portugal,Romania, Slovakia, Slovenia, Spain, Sweden, the UK and Norway. Latvia and Finland are notcovered by the study as they did not yet have an EIRO centre at the time of writing.

Health care sector contextThe European health care sector has a critical role to play in the achievement of the goals of theEurope 2020 strategy by contributing to the overall health and well-being of the workforce andsociety as a whole. In addition, the health and social care sector is also an important employer,whose significance is likely to grow in the context of demographic change. As a result, healthcare employers are not only affected by trends towards an ageing population in terms of the risingdemand this places on service delivery, but also in the context of emerging labour market

shortages resulting from declining birth rates.Expenditure on health care is also increasing as a result of ongoing advancements in medicalscience, making it possible to successfully treat and improve the prognoses for many conditions,which would previously have been unthinkable. Such developments have not only opened thedoor to more advanced (but often also expensive) treatments, but prolonging healthy life spans isalso contributing to the number of individuals living to a very old age. This increases the potentialto develop more complex ailments and raises the demand for long-term care services.

These developments are taking place at a time when health care funding systems are alreadycoming under pressure from increasingly tight budgets, both for the public purse and forhousehold expenditure, particularly in the context of the economic crisis.

This section summarises recent trends in expenditure on health care, employment and workingconditions in the sector and in health care policy.

Expenditure on health care

A number of factors are important when looking at overall expenditure on health care servicesand the funding of health care.

Demand for health care is potentially open ended, particularly with advances in thedevelopment of medicines and medical technology. Thus there has always been a system ofrationing, be it through a gatekeeper system, financial restrictions, decision about theapproval of drugs for widespread funding or indeed treatment decisions at the operationallevel.

As a result of, but also exacerbated by, medical advances and demographic change, evenwhere there have been significant increases in investment in the health care sector in recent

years, it is not easy for such investment to keep pace with the rise in demand (GHK, 2008).According to the most recent Eurostatdata, health care expenditure in Europe ranges between5.1% of GDP in Romania to 10.7% in France (Figure 1).
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Figure 1: Health care expenditure as a percentage of GDP, 2003 and 2007

Figure 1: Health care expenditure as a percentage of GDP, 2003 and 2007

Notes: See Annex 1 for country codes and groups.Data on health care expenditure are based largely on surveys andadministrative (register) data sources in the different countries. Theytherefore reflect the country-specific way of organising health care and maynot always be completely comparable. The database is based on cooperationbetween Eurostat, the Organisation for Economic Co-Operation andDevelopment (OECD) and the World Health Organization (WHO), whichhave executed a joint questionnaire on health expenditure since 2005. Thearea covered consists of EU27 (excluding Greece, Ireland, Italy, Malta andthe UK) plus Iceland, Japan, Norway, Switzerland and the USA.The latest available data provided by Eurostat are for 2008 but 2007 figuresare used as 2008 data are available only for a handful of countries. In theabsence of statistics for 2007, 2006 figures are used for Latvia, Norway,Portugal, Slovakia and the USA.Source: Eurostat, 2010

The most common method of funding health care in the EU is through a system of compulsoryhealth insurance, usually funded through a system ofemployer and employee payroll


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contributions, which is often complemented by some funding from general taxation. OnlyDenmark, Finland, Ireland, Malta, Portugal, Spain, Sweden and the UK have systems that arefunded largely from general taxation (with some out-of-pocket payment for particular items andservices).

In almost all cases, the share of private involvement in the health care sector is increasing, forexample through a reduction in services covered by health insurance funds, more out-of-pocket

payments, and an increase in private insurance and hospital care provision. Private, out-of-pocketpayments play an increasingly important role in health care expenditure in Austria (28%),Bulgaria (45.5%), Hungary, Poland, Romania (all over 30%) and Spain (23%) (GHK, 2008).

For the reasons outlined above, per capita health care expenditure rose in all European countriesbetween 2003 and 20072008 (most recent figures available) (Figure 2). Starting largely from alower base and often requiring significant investment to improve health care infrastructure, themost significant increases are found in the eastern European Member States (for example, 171%in Romania).

Figure 2: Percentage change in total health care expenditure, 2003 to 20072008 ( percapita)

Figure 2: Percentage change in total health care expenditure, 2003 to 20072008 (per capita)

Note: 2008 figures used for AT, CY, LT, PL, RO, SI and SE; 2007 figures for

BE, BG, CZ, CH, DK, DE, EE, ES, FI, FR, HU and NL; 2006 figures for LV,NO, PT, SK and US. 2005 figures for BE, LV and SK; 2004 figures for AT,LT and PL; 2003 figures for all other countries.Source: Eurostat, 2010

Table 1compares changes in hospital expenditure with resources for nursing and residential carefacilities; in the majority of countries, expenditure on nursing and residential care facilities hasseen a significantly higher increase. This appears in line with the trend towards an ageing

population, but is by no means true for all countries.


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Table 1: Health expenditure ( per capita), 20032008

Total expenditure Expenditure on hospitalsExpenditure on nursing

and residential carefacilities

2003 2008 Change 2003 2008 Change 2003 2008 Change

AT 2,819 3,354 19% 1,081 1,235 14% 216 242 12%

BE 2,838 3,084 9% 893 922 3% 300 342 14%

BG 173 261 51% 63 102 61% 1 2 54%

CY 1,003 1,269 26% 418 532 27% 25 32 28%

CZ 567 805 42% 260 365 41% 7 11 54%

DE 2,724 2,966 9% 810 880 9% 205 236 15%

DK 3,115 3,876 24% 1,383 1,792 30% 621 481 -22%

EE 319 610 91% 140 281 101% 4 15 296%

ES 1,471 1,911 30% 544 745 37% 68 100 48%FI 2,153 2,620 22% 786 941 20% 195 223 14%

FR 2,725 3,183 17% 969 1129 17% 158 215 36%

HU 590 719 22% 218 240 10% 16 22 42%

LT 292 607 108% 105 225 114% 5 9 86%

LV 350 432 24% 141 178 26% 10 12 25%

NL 2,641 3,097 17% 955 1,141 19% 325 371 14%

NO 4,087 4,676 14% 1,553 1,784 15% 714 812 14%

PL 317 623 97% 97 215 122% 4 8 128%

PT 1,220 1395 14% 458 519 13% 21 24 18%

RO 126 343 171% 59 134 128% 1 7 570%

SE 2,772 3,174 15% 1,281 1,488 16%

SI 1,045 1,451 39% 397 603 52% 50 77 56%

SK 482 579 20% 135 157 16%


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Notes: Total expenditure covers: hospitals; nursing and residential care facilities;providers of ambulatory health care; retail sale and other providers of medical goods;provision and administration of public health programmes; and general healthadministration and insurance. Hospital expenditure consists of expenditure related tolicensed establishments primarily engaged in providing medical, diagnostic andtreatment services (which include physician, nursing and other health services to in-patients) and the specialised accommodation services required by in-patients.Nursing and residential care facilities cover establishments primarily engaged inproviding residential care combined with either nursing, supervisory or other types ofcare as required by the residents.

For total expenditure: 2008 figures were used for AT, CY, LT, PL, RO, SI and SE;2007 figures for BE, BG, CZ, CH, DK, DE, EE, ES, FI, FR, HU and NL; 2006 figuresfor LV, NO, PT, SK and US; 2005 figures for BE, LV and SK; 2004 figures for AT, LTand PL; 2003 figures for all other countries.

For hospitals: 2008 figures were used for CY, LT, PL, RO, SI and SE; 2007 figuresfor AT, BE, BG, CZ, CH, DK, DE, EE, ES, FI, FR, HU and NL; 2006 figures for LV,NO, PT, SK and US; 2005 figures for BE, LV and SK; 2004 figures for AT, LT andPL; 2003 figures for all other countries.

For nursing and care facilities: 2008 figures were used for CY, LT, PL, RO and SI;

2007 figures for AT, BE, BG, CZ, CH, DK, DE, EE, ES, FI, FR, HU and NL; 2006figures for LV, NO, PT and US; 2005 figures for BE and LV; 2004 figures for AT, LTand PL; 2003 figures for all other countries.

Source: Eurostat, 2010

Employment in the health care sector

In 2009 over 21.5 million people worked in the health and social work sectors in 2009 in EU27(Table 2).

Table 2: Employment in the human health and social work activities sector(NACE Q), 2009 Q1

Country EmploymentAT 379,400

BE 581,700

BG 159,400

CY 14,800

CZ 318,000

DE 4,537,400

DK 496,100

EE 33,000ES 1,287,200

FI 387,300

FR 3,257,700

EL 229,400

HU 242,800


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Country Employment

IE 222,000

IT 1,680,400

LT 89,800

LV 48,300

LU 21,400

MT 11,100

NL 1,354,800

PL 894,700

PT 300,000

RO 382,300

SE 695,500

SI 52,800

SK 148,700

UK 3,740,500

EU27 21,566,600

Source: Eurostat, Labour Force Survey [DS-073433-Employment by sex, age groupsand economic activity (from 2008, NACE rev.2), (1000), data downloaded 18 March2010]

Employment in the sector largely increased over the last decade, although some countrieswitnessed a decline (Estonia, Lithuania, Poland and Sweden) (Figure 3). On the whole,employment in the sector in the EU15 grew more substantially than in the new EU MemberStates. Cyprus, Ireland, Luxembourg and Spain witnessed the most significant employmentgrowth in the sector between 2001 and 2008.


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Figure 3: Change (%) in employment in the health and social work sector (NACE N),

20012008, Q2, EU27 and Norway

Figure 3: Change (%) in employment in the health and social work sector (NACEN) between 2001 and 2008, Q2, EU27 and Norway

Notes: In the absence of the employment figure for 2008 Q2, the 2007 Q4figure is used for BG, SE and SI, and the 2008 Q1 figure for PL.Source: Eurostat, Labour Force Survey [Employment by sex, age groups andeconomic activity (1998-2008, NACE rev.1.1) (1000) (lfsq_egana), data

downloaded 8 August 2010], age group 1564.The workforce in the health care sector is dominated by women with no less than 78% of workers

being female. This share rose marginally in the EU15 from 79% in 2000 to 80% in 2006. In thenew Member States, there was a small decline in the share of women in employment in the sectorfrom 81% in 2000 to 80% in 2006 (European Commission, 2009).

Education levels in the health and social care workforce tend to be medium or high, with 40% ofworkers having a high level of education. This is 13% higher than in the whole economy.

Around 43% of workers in the sector were aged 40 or younger in 2009. However, the share ofyoung workers has decreased markedly since 2000 while the share of workers over 50 hasincreased, demonstrating an ageing workforce pattern reflecting an overall trend in the EU labourmarket. This means that the health and social care sector not only has to accommodate the

demands of an ageing population, but it has to do so with an ageing workforce.

Working conditions in health care

As outlined in a number of reports (Eurofound, 2006; GHK, 2008; Pillinger, 2010), low wagesand difficult working conditions in the sector remain important factors contributing to labour andskill shortages in many specific parts of the health care system, occupations and regions.

According to the report prepared by Pillinger (2010) for the European Federation of PublicService Unions (EPSU), pay levels in the health care, childcare, elderly and other care sectors are
http://www.epsu.org/http://www.epsu.org/http://www.epsu.org/


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low compared with the national average for jobs requiring a similar level of qualifications. This isparticularly true for relatively low-skilled care workers, particularly in residential care for theelderly, but also other low-qualified tasks in hospitals and other care environments.

Similarly, bearing in mind the predominance of women working in the sector, work organisationand working patterns are generally not seen to be conducive to encouraging recruitment andretention in the sector. Indeed, a report by the European Foundation for the Improvement ofLiving and Working Conditions (Eurofound) onEmployment in social care in Europe(Eurofound, 2006) found that, in Germany, 80% of workers in the social care sector leave their

jobs within five years. A significant number of women do not return to work in the sectorfollowing childbirth because of expressed difficulties in reconciling work and family life.

Another factor which is considered to militate against attracting more individuals to work (orstay) in the sector is a perceived lack of career opportunities often despite significantinvestment in initial training.

Finally, the high levels of pressure of the job are associated with stress at workand sometimesthe threat ofharassment and violence at work(often from patients and their relatives),

particularly in psychiatric care but also in care of the elderly. Coupled with a physicallydemanding working environment resulting from the nature of the tasks involved, as well as shift

work, this often leads to burnout and high staff turnover. The final section of this report examinesthe types of measures taken by social partners and other stakeholders to address some of thesefactors in order to increase recruitment and retention in the sector.

Key trends in health care policy

The challenges facing the health care sector now and in the decades to come cannot beunderestimated. The opposing demands of the need to contain costs and the increasingrequirements of an ageing population are increasingly likely to require difficult decisions on howhealth care is funded and provided.

Financial pressures on the health care system are not new and rationing of access andavailability to certain treatments, drugs and services is an inevitable part of a service wheredemand is always going to outstrip supply. As indicated above, even within universal health care

systems such rationing takes place (whether it is obvious or not) in the form of decisions overwhich drugs to approve for use and the length of waiting times, down to individual clinicaldecisions on which treatments to offer. In insurance-based systems such processes can be moreexplicitly expressed in the types of treatments covered or the level of reimbursement provided.This need to make hard choices on service provision becomes all the more acute in the face ofdemographic change and advancements in medical science and treatment regimes.

Although the general trend is towards increasing healthy life expectancy, the conditions sufferedin older age have become more complex while simultaneously becoming more treatable. Thismeans that, while individuals are keen to extend the period they can live more or lessindependently in their own home, they require ever more skilled individuals to support them intimes of serious ill-health. This has inevitable implications for the planning of provision, and theshape and skills of the health care workforce.

These changes are also occurring at a time of increasingly tight public budgets, in particular in theaftermath of the economic crisis. Many countries and individual health care providers arestruggling with cutbacks in public expenditure. While some are striving to mitigate the negativeeffect on public investment in the health care sector, it is clear that shrinking budgets will in manycases affect services and employment in the sector, with a number of countries alreadyannouncing recruitment freezes and pay cuts or pay restraint. Significant issues with staffrecruitment and retention, skill shortages and outward migration are also making it difficult tomeet the increasing demand for services across the EU and serve to highlight that the fact that the


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attractiveness of the sector remains relatively low and must be addressed if skilled staff are to beavailable as demand increases.

It is difficult to generalise key trends in the variety of health care systems across Europe ascountries seek to accommodate these challenges. However, a number of prevalent themes haveemerged which include trends towards the decentralisation, liberalisation and in some cases

privatisation of provision. Legislative changes have sought to increase patient rights and to limitemerging challenges related to undeclared workin the provision of long-term care. There is alsoincreasingly a shift away from hospital to community-based care for a range of client groups. Theofficial goal of such reforms is to:

meet client demands;

provide better and more personalised care;

improve working conditions;

create more and better jobs;

enhance the attractiveness of the sector.

In a number of countries, efforts have also been made to establish and improve systems to fundlong-term care.

Decentralisation

A key trend has been towards the decentralisation of provision and decision-making, offeringgreater autonomy to local hospitals and care providers over the services they offer, the running ofthese services and, in many cases, the remuneration of their staff. These steps have generally beentaken to provide services more closely linked to the requirements of the locality, but results havenot always been positive. The countries currently affected by the trend in decentralisation include

Norway, Romania, Slovakia and the UK.

In Norway, the health care system has historically been decentralised to the municipalities andthe county municipalities. However in 2002, due to major reforms, the hospitals wereorganised as four independent enterprises (regional health authorities). As a result, theindependent health authorities now have employer responsibilities in addition to beingresponsible for their own finances.

In Romania there are plans to decentralise health care services in respect of both structure anddecision-making by moving them from the umbrella of the Ministry of Health (MS) to thelocal public administration bodies.

Slovakia has also undergone major reforms, and during the period 19982006, deregulatedand decentralised health care providers. However, the reforms produced discrepancies in payand working conditions, which has led to staff shortages in some areas.

In the UK, a key policy and structural shift has occurred in the publicly managed part of thesector within the last five years with the transformation of many National Health Service(NHS) hospitals into Foundation trusts. Foundation trust status provides local managementwith greater autonomy with regard to the management of their funds, and the negotiation ofthe pay and conditions of employees.

Liberalisation and privatisation

Liberalisation and privatisation is a controversial issue, and in some countries, it is viewed as ananswer to addressing failed systems and increasing the quality of care. The countries affected bythis trend include Belgium, Cyprus, the Czech Republic, France, Germany, Greece, Italy, the

Netherlands, Norway, Poland, Slovenia and Spain.
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Opponents of moves towards greater privatisation of public provision raise concerns thatprivatisation is endangering a universal and more equitable system. Liberalisation has createdcomplex issues in some countries.

The most important change that has occurred in the Swedish health care system during the pastfive years is undoubtedly the liberalisation of the primary health care services, including geriatriccare. In 2009, Parliament passed a new law that enabled the public to choose between public and

private primary health care. A key challenge for the Swedish health care sector will be how tohandle the liberalisation of the primary health care services, while preserving the tax-fundedwelfare system. In Slovakia, the heath care reforms implemented between 1998 and 2006 alsoliberalised the system, aiming at greater competition and the expectation of resulting serviceimprovements.

In Belgium, private provision is growing in response to the unmet requirements of an ageingpopulation. This growing demand is also expecting higher quality standards, especially among thegrowing group of wealthier people who have private health insurance in addition to thecompulsory statutory health insurance. Belgium has also witnessed an increase in private-for-

profit establishments and, more recently, the appearance of foreign conglomerates. This includesthe establishment of publicprivate partnerships in building infrastructure and the outsourcing ofnon-critical business functions to private companies. The expansion of publicprivate

partnerships in infrastructure investment has also been a feature of reforms in the UK, wheremany new hospitals have been constructed with the assistance of private finance.

In Germany, the number of public hospitals is declining while private provision is increasing.Cuts in public funding by the federal states (Lnder) and the 2002 change to a case-based flat-

base remuneration system resulted in a wave of privatisations of formerly public hospitals. InGreece, private hospitals are increasing their market share compared with public hospitals, mainly

because of the perceived shortcomings of the public health care system. Private sector hospitalservices focus on niche markets selecting mainly lucrative, short-stay surgical procedures.Reforms have also been implemented in Romania, enabling the establishment of private medicalfacilities.

In Cyprus, the private sector experienced a significant growth spurt around the mid-2000s. More

recently, however, employment in this market segment has been declining and the number ofprivate hospitals also fallen due to stricter regulation of the operation of private hospitals. Franceis experiencing a blurring frontier between the private and the public health sectors due to thecontractualisation of care activities to private clinics that contribute to public health service

provision and to the reform of hospitals funding that brought the public sector closer to theprivate sector, establishing the remuneration according to the activity. Portugal has seen someexperiences with the private management of public hospitals.

The Netherlands introduced the Health Care Insurance Act to reform the health care structure intoa system of regulated competition. In 1998, Poland tried to introduce an act to restructure publichospitals into joint stock companies. However, this initiative was vetoed and the governmentintroduced plan B which allowed local authorities to apply for money to pay back the debts of

public hospitals. As a result, hospitals have been transformed into joint stock companies.

Shift to community-based care

Many countries have seen an expansion of community-based care, allowing individuals to accesshealth care support in the home or in expanded health care facilities in their locality rather thanutilising hospital facilities. This particularly applies in relation to the care of older citizens (thusmeeting their demand for greater independence), but is also true for some mental health and

primary health care services.


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In Cyprus, the Czech Republic, France, Ireland, Italy and Malta, there has been a shift towardscommunity-based care and away from hospital treatment. For some countries, this transformationis due to the changing nature of care, and in others it is directed at cost saving measures orincreasing the quality of provision.

In the Czech Republic, hospitalisations are decreasing and outpatient care is increasing, resultingin greater family involvement. In Italy, hospital care has also been decreasing and communitycare increasing since the 1990s in order to contain health costs due to a large public debt.A key trend in the heath care sector in Ireland is the expansion of primary care services anddevelopment of primary care team networks, which includes a shift to community-based care.

National policy in Ireland is currently striving to develop appropriate home and community carefor older people, with an aim of no more than 4% of people over age 65 using residential care.

In Malta, the public policy on long-term care is directed towards keeping people in their owncommunity setting. In Cyprus, the community care sector has grown along with the growth in the

public and private sectors.

France is also experiencing an increase in the provision of care at home (for example, homehospitalisation and nurses providing care provision at home). Between 2003 and 2007, thenumber of health care establishments participating in a partnership relating to home care

provision nearly doubled to 60.8%.

Views of social partner organisations

Trade unions and employer organisations have responded to and have influenced these key trendsin a number of ways, depending on their level of involvement in tripartite concertation,tripartite or bipartite bargaining at different levels. (See the next section for information aboutsocial partner organisations in the health care sector.)

The emphasis of their interventions and the focus of expressed views have been on the shape ofreforms, ensuring the attractiveness of the sector, and the need to ensure that quality jobs can becreated to meet additional demands in an increasingly difficult budgetary environment.

The majority of trade unions have expressed concern about trends towards the liberalisation and

privatisation of health care provision. These concerns largely relate to the equity of provision, butalso reflect uncertainty about the impact of such moves on wages, and terms and conditions ofworkers in the sector. While trade unions are in dialogue with employers and the government inDenmark, Slovenia and Sweden about the precise shape of reforms in order to ensure equitable,high quality outcomes, in other countries there is graver concern about the impact of plannedliberalisation and privatisation on the sector.

Employer organisations tend to be more supportive of reforms. In Poland, for example, employerorganisations generally support the far-reaching privatisation of health care services accompanied

by the regulations which grant equal access of private and public service providers to contractswith the National Health Fund and the introduction of private health insurance.

While employer organisations are generally supportive of more private sector provision, they arealso concerned that budgetary stringency will restrict the expansion of such publicprivate

partnerships. In the UK, NHS employers have generally supported decentralisation and thefinancially viable setting of terms and conditions. Similarly, Swedish employers in the sectorhave also generally been supportive of government reforms.

In Italy, trade unions are concerned that cost containment policies will lead to a creepingprivatisation of Italys national health service. In the Netherlands, unions are concerned about theeffects of the implementation of competition in the health care sector. They believe that marketregulation has not led to more efficiency and better allocation of resources in the sector.However, employers in the Netherlands stress the advantages of entrepreneurship and


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competition in health care, and believe it creates more diversity between health care providers.On the other hand, they are aware of the war on talent that is going to develop in the sector as aresult of the growing demand for qualified personnel. According to the employers, this growingdemand is the result both of the ageing working population as well as because health care is agrowth market.

Many trade unions are concerned with staffing issues and believe that the sector remainsunattractive to new job entrants and returners, largely because of poor pay and conditions. Pay isseen to be a critical factor in attracting workers to the sector, and the number of disputesconcerned with pay (see the final section of this report) underlines the efforts by trade unions totackle low pay in order to help recruit and retain staff. Pay parity between (and within) the publicand private sector is also an increasingly important issue as the organisation of the sector andwage bargaining becomes increasingly decentralised.

Employers in many countries are keener to preserve or ensure greater local flexibility in settingwages and terms and conditions in order to be able to respond to local circumstances. However,in a significant number of countries, employers interests are either (partly) represented by thegovernment or are constrained by the limited availability of public finances that control wagesetting, irrespective of their views regarding requirements to attract/retain more workers in thesector.

Trade unions and some employers also emphasise the importance of improving worklifebalance measures in a sector so dominated by female workers. Of similar importance is the needto continuously update the skills and capacities of the workforce to ensure they remain up-to-datewith advancements in medical technology, patient care and work organisation. This has led tonegotiations in many countries over regular access to lifelong learning opportunities. Forinstance, in the Netherlands, five (of the six) employer organisations in the sector haveconstructed a Labour Market Agenda 2015. In this they address ways to tackle the labourmarket problems including effective and efficient vocational training, and the attractiveness ofthe sector.

Staffing issues are a significant concern for social partners in the context of increasing demandfor health and social care resulting from demographic trends and ongoing improvements in

medical technology, procedures and pharmaceuticals. Therefore, there are concerns about currentand future skills shortages in the sector. In order to tackle the problem of underfunding in Austria,private sector trade unions have requested a social billion (1 billion) for the health care sectorin order to create 20,000 new jobs to address labour shortages in the sector. The French GeneralConfederation of Labour (CGT) also supports an ambitious policy of training and recruitment inorder to create about 100,000 jobs in public hospitals to improve the working conditions andstatus of existing jobs, thereby increasing the quality of care.

In Belgium, trade unions are united in their view that more jobs will be needed in the health caresector to cope with the pressure placed on the systems by the trends mentioned above. They arguethat increasing the number of open-ended jobs will help to decrease workload in areas where staffare overstretched. At the same time, the unions are keen to see less recourse being made to use oftemporary agency workand fixed-term work. Employers favour measures that would reduce

the administrative burdens on front-line staff and the development of measures which support theretention of older workers in the sector. The health sector trade unions in Romania are alsoconcerned about workload and argue that it is the loss of personnel through migration to otherlabour markets that has led to labour and staff shortages, and the overburdening of the remainingmedical staff.

In some countries a recruitment freeze has created challenges. For instance, Irish heath careunions have been critical of the Government moratorium on staff recruitment and promotion
http://www.cgt.fr/http://www.cgt.fr/http://www.cgt.fr/


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across the public sector. The Irish Health Service Executive (HSE) is generally more supportiveof government initiatives and policy in this sector.

Social partner organisationsThis section provides an overview of trade unions and employer organisations in the health care

sector. It should be read in conjunction with Annexes 2 and 3, which provide an overview of allbodies representing employees and employers in this sector. The analysis is based on theresponses of EIRO national correspondents and it must be borne in mind that fully comparableinformation is not available for all unions and employer organisations in the sector.

The section begins by setting out some of the specifics relating to industrial relations in thesector. These are largely influenced by:

the essential nature of the services being provided;

the organisation and funding of health care services (for example, public and private provisionand the particular role of the state as provider in many countries).

Specifics related to industrial relations in the health care sector

Overall, social partner organisations in the health care sector enjoy the same rights as trade unionsand employer representatives in other sectors. These are generally laid down constitutionally or inlabour law. Freedom of association is guaranteed in all countries studied.

With one exception, the same applies to the right to engage in collective bargaining. Thisexception relates to Germany, where religious health care organisations are not involved incollective bargaining. To be more specific, in Germany, around 34% of care in hospitals, 16% ofcare in rehabilitation clinics, 55% of residential care and 38% of outpatient care is provided by arange of charitable organisations (data from the Federal Statistical Office). Health care workersemployed by some of the religious charities (Protestant and Catholic charity organisations) arenot covered by federal labour law or the Works Constitution Act but by ecclesiastical labour law.Under this law, employment terms and conditions (Arbeitsvertragsrichtlinien, AVR) are set bycommissions consisting of employee and employer representatives. Consequently, there is no

collective bargaining with unions in the health care sector covering Protestant and Catholic healthcare organisations.

Limited rights to industrial action

The health care sector displays a number of specificities regarding the right to strike, largelyresulting from the fact that in many European countries the health care sector is classified as anessential service. These provisions highlight the inherent bargaining strength of trade unions inthe health care sector through the potential to cause disruption to vital services, but alsodemonstrate the limitations to their ability to fully withdraw labour. Information in the finalsection of this report on recent strike actions in the sector demonstrates how this instrument has

been used by trade unions over the years to enforce improvements in pay and working conditions.

In just over half of the countries studied (Belgium, the Czech Republic, France, Germany,

Greece, Hungary, Italy, Lithuania, Luxembourg, Malta, Poland, Romania and Slovenia), thehealth care sector is subject to specific rules or regulations regarding the right to take collectiveaction. Legislative measures restricting strike action in the health care sector usually govern themaintenance of an emergency (or vital) level of service. Because the health care sector isclassified an essential services sector in a number of countries, often only restricted/partial strikescan go ahead (for example, in Belgium, the Czech Republic, Estonia, Greece, Hungary, Ireland,Italy, Malta, Romania and Slovenia).
http://www.hse.ie/eng/http://www.hse.ie/eng/http://www.destatis.de/http://www.destatis.de/http://www.eurofound.europa.eu/emire/GERMANY/LABOURLAW-DE.htmhttp://www.eurofound.europa.eu/emire/GERMANY/LABOURLAW-DE.htmhttp://www.eurofound.europa.eu/emire/GERMANY/ECCLESIASTICALLABOURLAW-DE.htmhttp://www.eurofound.europa.eu/emire/GERMANY/ECCLESIASTICALLABOURLAW-DE.htmhttp://www.eurofound.europa.eu/emire/GERMANY/ECCLESIASTICALLABOURLAW-DE.htmhttp://www.eurofound.europa.eu/emire/GERMANY/LABOURLAW-DE.htmhttp://www.destatis.de/http://www.hse.ie/eng/


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The procedures which must be fulfilled in order to take strike action are usually governed by law.In the health care sector, these do not only relate, for example, to requirements such as givingadvance notice or carrying out ballots, but also stipulate the vital or emergency level of servicethat must be maintained during periods of strike action. For example, in the Czech Republic, thelegislation on collective bargaining (Act no. 2/1991 Coll.) stipulates that a strike of health orsocial care workers is illegal if it endangers lives. In practice, this means that emergency care

must always be available during a strike or other form of industrial action. Similarly, in Belgium,the health care sector requires the provision of minimum essential services in cases of strikeaction, which are governed by the 1948 Essential Services Act. Joint committees of employersand employees decide on critical service needs and how they can be met during the strike. Thestate intervenes only when the parties are unable to agree. In Greece, the obligation to run aminimum level of emergency service during a strike applies to the health sector in a similar wayto other emergency services (fire, police, etc.). In Malta, the Supplementary Provision of the 2002Employment and Industrial Relations Act stipulates the number and occupational profile of the

personnel required to run health care services during strikes. In Romania, it is the responsibilityof the leaders of strikes to ensure that at least a third of normal duties are carried out duringstrikes.

Ireland is the only country studied where a voluntary form of regulation is in place. A voluntary

code of practice governing industrial dispute procedures in essential services was agreed in 2003.Similar to legal provisions in other countries, it commits the parties to any disputes to maintainingan emergency level of service.

As indicated above, regulations often specify the notice period for any potential strike in thehealth care sector. This applies, for example, to Belgium, France, Italy, Lithuania and Slovenia.The notice period ranges from five days in France to ten days in Slovenia, and two weeks inBelgium and Lithuania. For example, it is the 1948 Essential Services Act in Belgium whichstates that a collective industrial action must be announced two weeks in advance. In Lithuania,the notice period for a strike is twice as long in the health care sector than in most other sectors(14 versus seven days).

Rules regarding the right to strike are the same for nurses and care workers in public and private

health care establishments in most of the countries studied. The situation is, however, different inFrance and Luxembourg. In France, health care professionals in public establishments or privateones providing public health services (PSPH) must give notice of a strike five days in advance. Aminimum service must also be maintained, which means that an employer can order employees tostay at work. At the same time, nurses and care workers in private establishments can call a strikewithout notice and the employer has no right to require workers to stay at work (to provide aminimum level of service) during a strike. Legislation regarding the right to strike is also stricterin the public than in the private health care sector in Luxembourg.

In Germany, restrictions on the right to strike are applicable only to health care workers inspecific third sector organisations. Carers working for the Red Cross do not have employee status(they are considered to be members, rather than employees, of the organisation) and hence theyare not allowed to go on strike. In a similar manner, industrial action is prohibited in Protestant

and Catholic charity organisations as they are covered by the ecclesiastical labour law rather thanfederal labour law or the Works Constitution Act. In Lithuania, the Labour Code prohibits strikeaction in first aid services.

There are no specifics in relation to the right to strike for employees in the health care sector inNorway. However, strikes have often been stopped by compulsory arbitration due to the dangerthey could pose to life and health. For example, early in 2010, a strike among nurses in

Norwegian private nursing homes was ended after 10 days by compulsory arbitration. In the sameyear, nurses strikes in state-owned hospitals and among municipal employees (involving allunions including unions organising health and care sector employees) ended with a new


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agreement after negotiations were resumed after a five-day strike in hospitals and a two-weekstrike in the municipal sector.

Health professionals in Bulgaria and Cyprus had no right to strike until recently. In Bulgaria, thelegislation regarding industrial action was modified in 2006, and in Cyprus, the restrictionregarding the right to strike in essential services (including hospitals) was abolished through anagreement between the social partners in 2004 (CY0404103F).

Trade unions in the health care sector

Number of trade unions

A multitude of trade unions is active in representing workers in the health care sector in most ofthe countries studied, with the exception of Slovakia (Table 3). In many cases this is becausedifferent trade unions represent specific occupational groups with their own particular interests.However, in some countries, trade union pluralism is also a feature of the industrial relationssystem. The highest number of trade unions representing workers in the sector can be found inBelgium (8), Germany (9), Hungary (10), Portugal (10) and UK (12). They are followed byCyprus and Spain with six unions each. Health care professionals are represented by only one

trade union in Slovakia and by two unions in the Czech Republic, Lithuania and Luxembourg.Other countries with a comparatively low number of unions active in the sector are Denmark,Estonia, Malta and the Netherlands.

Health care sector unions can be categorised into two broad groups:

general, cross-sectoral unions whose membership reaches other sectors beyond health care;

specialist unions representing only the workforce in the health care sector or specificoccupations.

General unions are involved in representing nurses and health care professionals in at least 15countries. In four of these countries (Austria, Belgium, Italy and Luxembourg) only generalunions are active in the health care sector and no specialist unions represent particularoccupational groups of workers.

In eight countries, particularly in eastern European Member States, specific unions for the healthcare sector or for specific occupations have emerged (Czech Republic, Estonia, Greece,Lithuania, Poland, Romania, Slovakia and Slovenia). These often include unions representing, in

particular, nurses and midwives.

Table 3: Trade unions in the health care sector, 2010

No. ofunions

No. ofunions for

specificsector

Public vs. privateParticipation in collective

bargaining

AT 4 0 Separate unions for public andprivate sector workers: twoprivate and two public sectorunions

Both private sector unionsinvolved in collective

bargaining

BE 8 0 Separate unions for public andprivate sector workers: fiveprivate and three public sectorunions

All involved in collectivebargaining

BG 4 2 All represent public sector All involved in collective


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No. ofunions

No. ofunions for

specificsector


bargaining

employees only bargaining

CY 6 1 Separate unions for public andprivate sector workers: twoprivate and four public sectorunions

At least four out of sixinvolved in collectivebargaining (no information isavailable for two unions)

CZ 2 2 All involved in collectivebargaining

DE 9 2 Public, public/private and thirdsector unions

All apart from one involvedin collective bargaining

DK 3 2 Same unions for public andprivate sector workers


EE 3 3 Same unions for public andprivate sector workers All involved in collectivebargaining

EL 4 4 Both public and private sectorunions

Two out of four involved incollective bargaining

ES 6 3 All apart from one (public)represent both public and

private sector workers.


FR 5 4 Same unions for public andprivate sector workers

At least four out of fiveinvolved in collective

bargaining (no information isavailable for one union)

HU 10 6 At least one union specific tothe public sector, othersrepresent public and privatesector workers.

All involved in collectivebargaining but at local level

IE 5 2 Unions representing bothpublic and private sectorworkers and public sectorworkers only


IT 5 0 At least three public sectorunions


LT 2 2 Same unions for public andprivate sector workers


LU 2 0 Same unions for public andprivate sector workers


MT 3 1 Same unions for public andprivate sector workers


NL 3 1 Same unions for public and All involved in collective


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No. ofunions

No. ofunions for

specificsector


bargaining

private sector workers bargaining

NO 4 2 Same unions for public andprivate sector workers

PL 5 5 Limited almost exclusively topublic sector workers


PT 10 4 Most unions represent workersin both public and privateestablishments.

All involved in collectivebargaining.

RO 4 4 Same unions for public andprivate sector workers


SE 4 1 Most unions represent both

public and private sectorworkers.

All involved in collective

bargaining

SI 4 4 All involved in collectivebargaining

SK 1 1 Limited almost exclusively topublic sector workers


UK 12 At least 8 Most unions represent bothpublic and private sectorworkers.


Notes: = information not available.

Comparable information was not available for all trade unions. This means, forexample, that the actual number of health sector specific unions can be higher insome cases than indicated.

Source: EIRO national reports on industrial relations in the health care sector, 2010

Public and private sector representation

Countries differ considerably in terms of how employees in the public and private health caresectors are represented.

Health care sector workers are represented by separate unions for private and public sectorworkers in Austria and Belgium. But in at least 13 countries (Denmark, Estonia, France, Ireland,Lithuania, Luxembourg, Malta, Netherlands, Norway, Portugal, Romania, Spain, Sweden and theUK), a unified system of union representation dominates. Unions in these countries typically

represent health care professionals from both the public and private parts of the sector. However,these unions tend to have a higher number of members from public operators as it tends to bemore difficult to reach and recruit nurses and care workers working in private health careestablishments (for example, Ireland, Malta, Sweden and the UK).

In some of these countries (such as Ireland, Portugal, Spain and Sweden), while most unionsrepresent both public and private sector employees, one or two specific unions have also emergedthat represent public sector workers only.


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In Bulgaria, Poland and Slovakia, trade union representation in the health care sector is almostexclusively limited to public sector employees and the private health care sector remainsessentially non-unionised.

In the majority of the countries studied, all trade unions participate in collective bargaining. Thetwo public sector unions for health care professionals in Austria and the two recently formedhealth care federations in Greece do not take part in collective bargaining.

Otherwise, most unions take part in company, sector and/or cross-sectoral bargaining, dependingon the dominant level of collective bargaining in the country (see final section of this report).

Reorganisation of the structure of trade unions

The trade union structure has remained stable over the past five years in most of the studycountries.

Changes in the organisational structure of trade unions has been most widespread in Austria, butmergers between health care sector unions have also taken place in Malta and the UK, whilesplits have occurred in Greece and Poland. Brand new unions have been established in Romaniaand Slovenia, and one German health care sector trade union disbanded in 2009 due to acontinuous decline in membership.

The mergers in Austria, Malta and the UK have mainly involved larger cross-sectoral unions withsome health care sector representation. In Austria, a merger between three (mainly) blue-collarunions created the vida trade union in 2006. The union represents employees in a range ofoccupations, including truck and engine drivers, waiters and nurses. It has some 150,000members of which 7,000 are nurses. Further mergers, caused primarily by a decline inmembership and subsequent financial instability, took place in 2007 between other cross-sectoralunions active in the health care sector. These mergers resulted in the formation of two (GPA-djpand GdG-KMSfB) of the other three active unions in the health care sector.

In the UK, one major merger occurred in 2007 where Amicus and TGWU merged to becomeUnite the Union. Unite is the UKs biggest union with over 1,600,000 members and has about100,000 members in the health sector.

New unions have been established over the past five years in Romania and Slovenia. The CentralNational Trade Union of Health and Social Care (Centrala Naional Sindical din Sntate iAsisten Social) was formed in Romania and very recently a trade union called FLORENCEwas established in Slovenia which represents about 200 nurses. The main reason for establishingFLORENCE was dissatisfaction with the work ofSDZNS (the main union representing nurses inSlovenia) which was, in the nurses opinion, neglecting the promises made by the government toequalise the terms and conditions of nurses with higher vocational qualifications with thoseholding university degrees.

Following splits between unions, health care professionals in Greece and Poland have set up newunions. For example, the National Confederation of Trade Unions for Health Workers(OKZZPOZ)was formed in Poland following a split from a regional structure of a largerfederation of health and social care professionals(FZZPOZiS).

Rivalries between unions in the sector

Overall, relations between trade unions within the same sector are characterised by cooperation.EIRO correspondents have reported some rivalries in about a third of the countries covered bythis study. These rivalries were considered serious in three countries.

The good cooperation in most of the countries studied is fostered by the fact that clear boundariesexist in many of them between the occupational and organisational domains covered by differentunions. Furthermore, competition between unions is reduced when the public authorities consult
http://www.vida.at/http://www.vida.at/http://www.gpa-djp.at/http://www.gpa-djp.at/http://www.gdg-kmsfb.at/http://www.gdg-kmsfb.at/http://www.unitetheunion.org/http://www.unitetheunion.org/http://www.sdzns.si/http://www.sdzns.si/http://www.wfzzpoz.pl/http://www.wfzzpoz.pl/http://www.fzzpozips.com.pl/http://www.fzzpozips.com.pl/http://www.fzzpozips.com.pl/http://www.wfzzpoz.pl/http://www.sdzns.si/http://www.unitetheunion.org/http://www.gdg-kmsfb.at/http://www.gpa-djp.at/http://www.vida.at/


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all the unions on relevant public policy issues and where the unions represent similar views andstandpoints. The spirit of cooperation between unions can also be strengthened by the rulesgoverning national trade union confederations that stipulate strict rules and procedures regardingcompetition to represent members.

There is some degree of competition between health sector unions in Belgium, the CzechRepublic, Estonia, France, Greece, Norway, Portugal and Slovenia. Rivalry is more apparent incountries such as Germany, Italy and Malta. Despite the rivalry, many unions still tend tocollaborate on matters concerning collective bargaining, professional development of nurses andcarers, and public policy consultations.

In many cases the rivalry is local and based on competition over members (for example, Belgium,Estonia, Malta, Norway and Slovenia). This is particularly true for countries where the domainsof health sector unions overlap such as in France. In Belgium, local level competition exists

between different health care sector unions in both the public and private sectors. However, theunions are unified in their approach to collective bargaining, public policy consultations and theimplementation of policy priorities.

A conflict has emerged in Germany where two unions have a disagreement over a new collectiveframework agreement for the public part of the sector (DE0607019I, DE0503203F). Rivalry is

apparent between the United Services Union (ver.di) and Marburger Bund (MB), a trade unionrepresenting medical doctors. In 2005, MB decided to opt out of a bargaining alliance with ver.dibecause it believed that better terms and conditions could be achieved for staff through separatenegotiations. Ver.di criticised MB for this move and insisted on its right to negotiate for all staffin the heath care service.

Rivalry is also clear in Italy and Malta. In Italy, competition exists between the three traditionalunion confederations and the more contemporary confederations, which claim to defend workersinterests more genuinely. However, all representative unions signed the last collectiveagreements. In Malta, competition stems from power struggles between unions over members andthe rivalry tends to be particularly fierce among public sector unions. Various disputes have taken

place between public health care unions; the General Workers Union (GWU) and the Union ofUnited Workers (UHM). These unions have a more cooperative relationship with the emerging

professional associations in the sector than with one another.

Relationship between unions and new emerging professional organisations

As indicated above, the relationship between traditional trade union organisations and newprofessional associations of health care workers varies from one European country to another.Professional organisations tend to be established to further the interests of a particularoccupational group in matters going beyond wages, terms and conditions. Although trade unionscollaborate well in many countries with such professional associations on matters of commoninterest, this relationship is more difficult for example in Estonia, France, Italy and Poland.

France has seen strong opposition against the recent law that established a professionalassociation for nurses. Nurses dislike being made to pay a fee to this association and the unionshave questioned the representativeness of the association; the protests against the new associationhave culminated in strikes calling for its closure. In Italy, the overlap between the activities ofunions and professional associations has caused occasional conflicts. In Estonia, the competition

between unions representing nurses emerged when the professional association of nurses(Estonian Nurses Union, EL) transformed its organisational status into a trade union. Thismeans that nurses are now represented by two dedicated unions.
http://www.verdi.de/http://www.verdi.de/http://www.marburger-bund.de/http://www.marburger-bund.de/http://www.gwu.org.mt/http://www.gwu.org.mt/http://www.uhm.org.mt/http://www.uhm.org.mt/http://www.ena.ee/http://www.ena.ee/http://www.ena.ee/http://www.uhm.org.mt/http://www.gwu.org.mt/http://www.marburger-bund.de/http://www.verdi.de/


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Employer organisations in the health care sector

Number of employer organisations

In many countries, employers interests are represented by several organisations, often dependingon the precise nature of health care provision, financing and industrial relations traditions. By farthe largest number of representative organisations can be found in Belgium (13), followed byGreece and Italy with 10 employers organisations per country (Table 4). Six or moreorganisations are present in Austria, the Czech Republic, Denmark, the Netherlands, Poland andSpain. Hungary is not far behind with five representative organisations. Two representative

bodies can be found in Cyprus, Ireland and Portugal. Three smaller Member States (Estonia,Lithuania and Malta) have a single organisation representing health care providers.

The low number of employer organisations in, for example, Cyprus is explained by the fact thatthe ministry in charge of health handles most of the bargaining in the public part of the sector.This is also the case in Greece and Romania. In Belgium, the high number of employerorganisations partly reflects the regional structure of the country (Walloon and Flanders).

Table 4: Employer organisations in the health care sector, 2010

Totalnumber

Numberspecific tothe health

caresector *

Organisational domain:public, private, private,

third sector

Participation in collectivebargaining

AT 7 5 Four third sector, twoprivate and one for publicsector employerorganisation

All involved in collectivebargaining except one publicsector organisation

BE 14 13 Private, public and thirdsector organisations


BG 4 2 Separate private and publicemployer organisations


CY 2 1 All private All involved in collectivebargaining

CZ 6 6 Some private (membershipnot clear for all)

None involved in collectivebargaining

DE 5 2 Two public, two privateand one third sectororganisation

DK 6 2 Three private, two public

and one third sectororganisation

All involved in collective

bargaining

EE 1 1 All involved in collectivebargaining

ES 6 6 All involved in collectivebargaining (no informationavailable for all


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Totalnumber


caresector *


third sector


organisations)

FR 3 3 One public, one privateand one mixed(private/third sector)organisation


EL 10 10 All private All involved in collectivebargaining except one

HU 5 5 All involved in collectivebargaining

IE 2 1 One private and one mixed(public and private)


IT 10 6 Six third sector, threeprivate and one publicemployer organisation


LT 1 1 Mixed public and privaterepresentation


LU 4 2 Mixed All involved in collectivebargaining

MT 1 0 Mixed (public and private)representation


NL 6 6 All involved in collectivebargaining

NO 4 0 Public and private sectoremployer organisations

All involved in collectivebargaining (no informationavailable for allorganisations)

PL 6 4 Four private and twomixed public and privatesector organisations


PT 2 2 Private sectororganisations


RO 5 1 Public and private (3)employer organisations


SK 4 4 Public and private (2)employer organisations


SI 3 3 Mixed (public and privatesector) organisations

Only one involved incollective bargaining


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Totalnumber


caresector *


third sector


SE 5 1 Two private, one public,one mixed (private/public)and one third sectororganisation


UK 4 4 Public

Notes: = information not available.

* In some cases, the actual number of health care sector specific employerorganisations can be higher. Due to the lack of information for all organisations, itwas not possible to determine the domain of all organisations.

Source: EIRO national reports on industrial relations in the health care sector, 2010

Public, private and third sector representation

In contrast to trade unions where many organisations cover employees of both the public and theprivate parts of the sector, representation of employers is more likely to be split according to thenature of provision (public, private and third sector) (Table 4).

Separate employer organisations for public and private providers exist, for example, in Austria,Belgium, Bulgaria, Denmark, France, Germany, Ireland, Italy, Norway, Poland, Romania,Slovakia and Sweden. However, there are also some employer organisations representing both

public and private sector providers in Ireland, Lithuania, Luxembourg, Poland, Slovenia andSweden.

In the private sector, employer organisations tend to represent either private hospitals or privateresidential care facilities.

In the public sector, employers interests are often represented by the respective ministry ofhealth, particularly if the majority of health care is state provided and funded. As described inmore detail in the next section, this can have a crucial impact on collective bargaining. This isespecially true for health care employees in the public sector who have the status of civil servants,as they often have their terms and conditions fixed in legislation (rather than by collectiveagreement).

Separate organisations for third sector employers (especially providers run by churches andreligious organisations) exist for example in Austria, Belgium, Denmark, France, Germany, Italyand Spain.

General and specialist employer organisations exist in parallel in half of the countries studied.General employer organisations represent the interests of employers beyond the health care sector(of either the public or private sector), whereas specialist employers focus solely on representing

health care establishments. General employer organisations are often found in the public sector,especially in countries where employers essentially represent the employer interests of allregional or municipal public services (such as in Denmark, Finland or Sweden).

Employer organisations specifically representing providers in the health care sector have beenreported in 10 countries (the Czech Republic, Estonia, France, Greece, Lithuania, the

Netherlands, Slovakia, Slovenia, Spain and the UK). Specific organisations can represent publicproviders, or indeed the state health care system, as is the case withNHS Employers in the UK,or the French Hospital Federation (FHF), but they can also be found among private providers as
http://www.nhsemployers.org/http://www.nhsemployers.org/http://www.gipspsi.org/GIP/membres_et_partenaires/members/fhf__1http://www.gipspsi.org/GIP/membres_et_partenaires/members/fhf__1http://www.gipspsi.org/GIP/membres_et_partenaires/members/fhf__1http://www.nhsemployers.org/


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is the case in the Czech Republic and Greece where they represent, for instance, private hospitals,private clinics or private nursing homes.

In the majority of countries, all employer organisations participate in collective bargaining.Exceptions are the Czech Republic, Malta and Poland where employer organisations in the healthcare sector do not participate in collective bargaining and agreements are reached atestablishment level. In some other countries (for example, Austria, Greece and Slovenia), all butone take part in bargaining either at cross-sector, sector or local level. Where employerorganisations are not involved in collective bargaining, it is generally because they are notmandated to do so by their members, and their activities are limited to representing the interestsof their members in social dialogue or providing advice on bargaining outcomes reached at thelocal level.

On the whole, employer organisations in the eastern European Member States tend to have ashorter tradition and are organisationally and economically weaker. In many cases they areinvolved in collective bargaining only at local level.

Reorganisation of the structure of employer organisations

After some years of rapid change in the representation of employers (particularly in the 12 new

EU Member States following accession in 2004 and 2007), the landscape for employerorganisations in the health care sector has remained relatively stable over the last five years.Relatively few reorganisations have taken place. Over half of the countries studied (15) witnessedno major reorganisations, while 10 have experienced some degree of reorganisation over the pastfive years. Mergers, splits or other forms of restructuring have taken place in Belgium, Denmark,Germany, Ireland, Italy, the Netherlands, Poland, Slovakia, Spain and Sweden.

Structural reforms of the health care sector or the reallocation of responsibilities between thestate, regions and local authorities have led to reorganisation in the health care sector in Belgium,Denmark, Ireland and Slovakia. In Denmark, the setting for employer organisations has beenadjusted to take into account of the change in prerogatives between the state, regions andmunicipalities (the health care sector is now the responsibility of the regions and municipalities).In Ireland, the Irish Government disbanded the public health boards in 2005. They were

reorganised into the HSE, which took over full operational responsibility for running Irelandspublic hospital and other heath care services. In Slovakia, heath care reforms have brought newroles for larger, state-owned hospital (as opposed to small and private hospitals). As aconsequence, the association representing hospitals was split into two organisations in 2006.

Employer organisations have merged in Germany, the Netherlands and Sweden. In Germany, anew employer association of private care providers was established in 2009. ArbeitgeberverbandPflegewas established by eight companies involved in health care services and the federalassociation of providers of private social services (bpa) to establish a body which could concludea sectoral agreement with the German Trade and Industry Employees Association (DHV) andthe health trade union, medsonet. In Sweden, the Swedish Association of Local Authorities andRegions (SALAR) was created in 2007 after a merger of the municipality and countyassociations, and ActiZwas created in the Netherlands as a result of a merger of two smaller

employer organisations in the sector. ActiZ represents nursing homes, homes for the elderly andproviders of home care, youth health care and maternity care.

Employer organisations have split into smaller units in Italy and Slovakia. For example, in Italy,the reorganisation of the federation of national cooperatives, Legacoop, which took place in 2005,resulted in the creation of a specific employer organisation for social and health carecooperatives.
http://www.arbeitgeberverband-pflege.de/http://www.arbeitgeberverband-pflege.de/http://www.arbeitgeberverband-pflege.de/http://www.bpa.de/http://www.bpa.de/http://www.dhv-cgb.de/dhv_datahttp://www.dhv-cgb.de/dhv_datahttp://www.medsonet.de/http://www.medsonet.de/http://english.skl.se/web/english.aspxhttp://english.skl.se/web/english.aspxhttp://www.actiz.nl/http://www.actiz.nl/http://www.legacoop.it/http://www.legacoop.it/http://www.legacoop.it/http://www.actiz.nl/http://english.skl.se/web/english.aspxhttp://www.medsonet.de/http://www.dhv-cgb.de/dhv_datahttp://www.bpa.de/http://www.arbeitgeberverband-pflege.de/http://www.arbeitgeberverband-pflege.de/


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A new, informal umbrella organisation for employers in the health care sector was established inPoland in 2006. The Healthy Health Corporation (Korporacja Zdrowe Zdrowie) represents threeemployer federations and some individual employers in the sector.

Rivalries between employer organisations in the sector

On the whole, there is less competition between employer organisations than trade unions in thesector, as demarcation between organisations is fairly clear, reducing competition over members.Some degree of rivalry was reported by EIRO correspondents only between employerassociations in Austria, Denmark, Germany, Spain and Sweden. The most important examples areAustria and Spain. In Austria, many different collective agreements cover pay and workingconditions of health sector workers, causing rivalry between employer organisations in the sector.Two employer organisations, the Association of Health Companies ( FVG) and the Association ofPrivate Hospitals in Austria (VP) also compete over the right to conclude collective agreements.The conflicting interests and priorities of some Spanish employer organisations in the sector havecreated a climate of hostility between different organisations. Some employer representativeshave also questioned the representatives of other employer organisations involved in collective

bargaining in the sector.

Collective bargaining, social dialogue and industrial action inthe sectorFor the purposes of this study, a distinction is made between collective bargaining and socialdialogue, with collective bargaining referring to bipartite negotiations between employers andtrade unions on wages, and terms and conditions of employment, taking place at differentlevels. Social dialogue on the other hand is taken to refer to a range of bipartite and tripartiteinformation, consultation and negotiating arrangements not related to the terms and conditions ofemployment. This includes tripartite concertation, which refers to institutionalised arrangements(usually at national level) that allow social partner organisations to be consulted by governmenton a wide range of policy issues.

This section begins by examining the structure and nature of collective bargaining in the health

care sector, its coverage, and the possibility of extending collective agreements and anyderogations or opt-outs that can be applied. The second part focuses on social dialogue structures,

processes and issues discussed within such fora in the health care sector. The final sectionexamines industrial action in the health care sector over the past five years.

Collective bargaining

Structure and level of collective bargaining

In most European countries, the structure of collective bargaining in the health care sector isconditioned by the nature, funding and organisation of health care provision (the mix of public,

private and voluntary provision and the level of responsibility for managing the service nationalgovernment, municipalities, voluntary organisations at different levels, etc.). The most significantdistinction in the level and nature of bargaining can be found between public and private sector

providers.

Setting wages and terms and conditions in the public sector

In the public sector, wage setting tends to be centralised either at national or regional level.Negotiations on salaries and terms and conditions can depend on the status of the employee (civilservant or employee under the standard labour code). The terms and conditions of civil servantsare usually laid down in legislation (for example, in Cyprus, France and Greece), whereas
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settlements for other public sector workers are negotiated between the government and publicservice trade unions. However, this is not the only reason for the complexity of bargainingarrangements in the public sector. Differences can also be found in the nature of the parties taking

part in bargaining processes, whether these are bipartite or indeed tripartite (involving employerorganisations and the state as well as the unions), the level of bargaining (national or regional)and the level of detail covered by collective bargaining at central level and, as a result, the

extent of local leeway to further shape pay and conditions.The precise shape of collective bargaining in the public sector is also influenced by:

particular responsibilities for health care provision in different countries;

the level of local autonomy provided (in additional to national bargaining);

the strength and maturity of employer organisations in the sector.

In the public sector, these factors tend to be paramount to general industrial relations traditions,although they clearly do have an influence. (See TN0611028S for an overview on industrialrelations in the broad public sector.)

In Belgium, Lithuania and Portugal, for example, negotiations take place between trade unionsand the state as employer. In Belgium, the federal structure of the state means that national

agreements have to be translated into agreements at regional level. In Lithuania, the outcome ofsuch centralised bargaining does not take the shape of a collective agreement, but of legislationon the general financial perspectives which set the framework for further negotiations at locallevel. In Portugal, negotiations take place, but decisions can ultimately be taken by thegovernment unilaterally.

Collective bargaining between trade unions and public authorities at regional level takes place inthe public sector in Austria, Denmark, Finland, Germany, Spain and Sweden. In Austria, thesenegotiations are directly between the trade unions and theLnder. In Germany, these negotiationsare carried out by the Confederation of Municipal Employers Associations (VKA) and TdL (theemployer organisation for theLnder) for the health care providers in their purview (althoughthese negotiations no longer cover all regions). In Spain, public service bargaining for the healthcare sector is the responsibility of the autonomous regions. In the Nordic countries, bargaining is

also carried out at regional level, with local or regional authority employers.In Ireland, Italy, Luxembourg, the Netherlands, Slovakia and the UK, bargaining in the publicsector is between national employer organisations and trade unions. In Estonia, an agreement has

been signed between the national employer organisation in the sector and the trade unions on aminimum wage.

In countries where public service provision is paramount, bargaining at this level often has aguiding function, with private sector settlements shadowing public sector deals. Public sector

bargaining is generally constrained by overall public spending plans or the level of publicinsurance levies. Like the trend in health care policy, there has been a move towards thedecentralisation of management which has meant that, even in the public sector, more and morelocal autonomy is being granted to further shape collective bargaining outcomes.

Setting wages and terms and conditions in the private sectorMany private providers only bargain at the local level, although there are some exceptions to thisrule in cases where there are strong private sector employer organisations engaging in multi-employer bargaining. Multi-employer bargaining at national level takes place in Austria,Belgium, Finland, France and Slovakia. However, bargaining in the private sector is entirelydecentralised in the majority of member states in eastern Europe (for example, in the CzechRepublic, Hungary, Poland and Romania), as well as in Cyprus, Germany, Greece, Malta and theUK.
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In Austria, the sectoral agreement concluded between the Professional Association of Employersfor Health Care and Social Workers (BAGS) and the trade unions, GPA-djp and vida on behalf ofemployees, represents the only sector-wide collective agreement covering the whole health careand care sector including work with the disabled, children and youth welfare and the provision oflabour market policy services.

In Belgium, collective bargaining in the private sector takes place in joint committees. Separatecommittees exist for health care providers and care providers. Although negotiation andconsultation in the public sector must take place between trade unions and the government whichcan lead to agreements and protocols, these have no legal standing and the government can actunilaterally. Bargaining is carried out in three committees (Committee A covering all publicsector workers at federal level, Committee B which contains 15 different sectoral bargainingcommittees and Committee C where protocols are negotiated for workers in different provincialand local administrations). In the la

Employment and Industrial Relations in the Healthcare Sector

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